Navigating insurance claims, appeals and getting the appropriate insurance coverage for eating disorder treatment can be a challenging process. This section includes resources including letter templates, tips regarding appeals and fighting for coverage, and local mental health insurance information.
Read more from National Eating Disorders Association (NEDA): Insurance Resources
Insurance Coverage: Tips for Navigating
Eating disorders, particularly anorexia and bulimia, are usually covered by health insurance, partly as a result of the “parity law” now in effect in California, but figuring out exactly what the coverage is can be confusing. The parity law states that certain mental health disorders, including anorexia and bulimia, will have the same maximum co-payment as those in the general medical plan. This short guide will give you some basic information to help you get the benefits to which you are entitled and also to make decisions about maintaining insurance coverage for the future.
First, you should review and be aware of the details of your policy and contract. The major insurance companies vary tremendously as to what they will cover, and every insurance company has hundreds of different policies, each with its own coverage and terms. In addition, major insurance companies often have mental health benefits, under which eating disorders coverage falls, administered by a secondary company. The best way to be clear about your benefits and your payment responsibilities is to actually read all the information sent to you about your plan, as well as any updates. While reviewing all the specifics of your policy may seem like a daunting and unpalatable task, it is well worth the time since treatment of eating disorders can be very costly.
If you still have questions about your coverage after reviewing the policy, contact your health insurance company for further explanations. Ask to speak to the insurance company representative’s supervisor for further clarification if the answers you are given do not seem to fit with the terms of your policy as you understand it. You can also ask for help from your employer’s human resources department.
Remember that you are your own best advocate when dealing with your health insurance coverage issues. You should also be aware that all insurance companies have an appeal process whenever a claim is denied, and in some cases denials of coverage are overturned on appeal.
As the parent of a son or daughter with an eating disorder, you should keep in mind the issue of ongoing, long-term health insurance coverage. It is especially important that a person with any serious or pre-existing medical condition, which includes anyone with an eating disorder, never let health insurance coverage lapse. It is likely to be difficult and extremely expensive, if not impossible, to obtain or reinstate new insurance coverage. If your child’s insurance coverage is due to end because a parent changes jobs or is laid off, or because the child will pass the age under which they are covered, be sure to check with your health insurance company and your company’s human resources department to find out how coverage can be continued. You can also contact an insurance agent to find out what options you may have for health insurance, but be sure to explain fully your child’s medical history.
Again, make certain that you consider and settle this question before your child’s coverage ends, so that there will be continuous insurance coverage.
Strategies to Counteract Insurance Denials
Information from an insurance panel at NEDA conference with:
- Attorney Lisa S. Kantor, Esq., of Kantor & Kantor LLP, Northridge, CA
- Stacey Brown, Director of Nursing and Utilization Review
- David Christian, Clinical Psychologist, Avalon Hills Eating Disorders Treatment Program
Common Reasons Claims Are Denied
The panel outlined out three common reasons insurance claims are denied. The first reason involves the question of medical necessity. Parity laws require that mental health coverage be provided commensurate with medical health coverage. Second, medical stability will occur long before psychological stability. State definitions trump an insurer’s definition of medical necessity. Finally, clinicians should look for loopholes.
A second reason is exhaustion of benefits. To counteract this, clinicians, family, and patient should be very familiar with the individual policy because the company may deny benefits that are clearly included. It is also helpful to know the state’s degree of involvement with mental health parity laws, because the state may or may not participate in parity. A third reason for denial is rigidity about what the insurer thinks treatment be; for example, telephonic family treatment or partial treatment with boarding (one can legally bill for a lower level of care than what is being delivered). And, some companies attempt to selectively exclude eating disorder patients.
Read more from Eating Disorders Review:
When to challenge insurance denials and other useful information
How to fight for coverage of eating disorder treatment
Eating disorders can be both medically and financially devastating. The National Eating Disorders Association says as many as 10 million women and 1 million men in the U.S. battle anorexia or bulimia, and another 13 million more struggle with binge eating or an obsession with dieting. Worse, kids as young as 8 and 9 are being diagnosed with eating disorders and adolescent girls are still the No. 1 demographic for developing an eating disorder.
Read more from this Nasdaq article:
How to Fight for Coverage of eating disorder treatment
Local Mental Health Insurance Referral
County 60-Day Program
Mental Health Advocacy Project (MHAP)
152 North Third Street, 3rd Floor
San Jose, CA 95112
(Across from Saint James Park on Third Street)
Phone (408) 280-2407
MHAP is working on a statewide initiative to spread the word about mental health parity laws. The basic principle is that health insurance companies must cover mental health and substance abuse disorder benefits equally to other health benefits. With the Affordable Care Act, parity laws apply to more types of plans than ever before, so MHAP is trying to get the word out about parity protections through trainings. In some cases, MHAP can also provide direct representation for people who run into problems with their health plans. Click here to view a flyer and FAQ about the parity project.
Healthy Families and Healthy Kids (by Santa Clara Family Health Plan)
PCP sends prior authorization referral to Santa Clara Family Health Plan: (408) 376-3532 (fax)
Once authorized, County Mental Health phones patient for an autom 3 visits. Thereafter, therapist requests more visits as needed. See additional information below under Santa Clara Family Halth Plan.
MediCal and Managed Care MediCal
Self-referral to County Mental Health Department: (800) 704-0900
Blue Cross Healthy Families Behavioral Health Programs: (800) 399-2421
Santa Clara Family Health Plan
210 E. Hacienda Avenue
Campbell, CA 95008
Santa Clara Family Health Plan is committed to providing quality, affordable health coverage to the uninsured and underinsured in Santa Clara County’s diverse communities. Medi-Cal coverage is free, while Healthy Families and Healthy Kids costs no more than $18 a month per family, depending on family income. As the designated community provider plan for Healthy Families in Santa Clara County, Santa Clara Family Health Plan offers these low rates for all the same benefits as the commercial plans. Santa Clara Family Health Plan is the exclusive plan to offer Healthy Kids benefits. Member benefits include comprehensive medical care such as preventive checkups, specialist care, a 24-hour nurse advice line, hospital care, prescriptions and many other services.
Santa Clara County Mental Health Department
They do not specifically have any programs for eating disorders. Patients suffering from an eating disorder enter the system through this portal: http://www.sccmhd.org/portal/site/mhd/.
Valley Health Plan Commercial
Counseling, self-referral: (408) 885-4647
12 visits, then therapist submits a treatment plan for additional visits
Psychiatry, requires Primary Care Physician referral by fax to: (408) 885-4875
5 visits, then psychiatrist submits for additional visits.
Santa Clara County Emergency Psychiatric Services (EPS)
871 Enborg Lane
San Jose, CA 95128
Available 24-hours a day. Evaluation, assessment, treatment and observation, and referral to appropriate care, including admission to a hospital when needed.
Santa Clara County Mental Health Urgent Care
871 Enborg Ct.
San Jose, CA 95128
8am-10pm daily; walk-in or by appointment
Walk-in outpatient clinic for Santa Clara County residents experiencing a mental health crisis. Provides screening, assessment, crisis intervention, referral and short-term treatment for adolescents and adults.
Santa Clara County Suicide and Crisis Hotline
24-hours a day
Provides phone intervention and emotional support to individuals in crisis. Highly trained volunteer counselors assist people who are feeling suicidal, experiencing distress, or just need to talk with someone who will listen.
Santa Clara County Mental Health Call Center
For information regarding behavioral and mental health services (including eating disorders), screenings, appointments, benefits and authorizations.
Valley Connection is the appointment line for Santa Clara Valley Medical Center’s primary care clinics. You can call Valley Connection to make an appointment with a SCVMC primary care physician (PCP), get a Medical Record Number, and Locate services. If you do not have a primary care physician, please contact your health plan to find out how to select your PCP.
1-888-334-1000 (English, Spanish, Vietnamese, and a number of other languages)
Example of a Follow-up Letter from Parents
Example of a Letter from a Physician
- Secondary amenorrhea since August 200X. This prolonged amenorrhea has the potential to cause irreversible bone damage leading to osteoporosis in her early adult life.
- As above, significant risk for Osteopenia. Bone density results are pending examination.
- Essential fatty acid deficiency, which can impact all organs, most especially her neurocognitive function.
- Constipation, delayed gastric transit, and abdominal pain
Example of an Appeal Letter From Parents
The Insurance Appeal Pack
In addition to a letter and many forms required by the insurance company, include the following:
1. American Psychiatric Association (APA) Guidelines for Treatment of Eating Disorders
Important medical findings reviewed in the APA guidelines
- Physical consequences of eating disorders include all serious sequelae of malnutrition, especially cardiovascular compromise.
- Prepubertal patients may have arrested sexual maturity and growth failure
Even those who “look and feel deceptively well,” with normal EKGs may have cardiac irregularities, variations with pulse and blood pressure, and are at risk for sudden death.
- Prolonged Amenorrhea (less than six months) may result in irreversible Osteopenia and a high rate for fractures.
- Abnormal CT scans of the brain are found in less than 50 percent of patients with anorexia nervosa.
- Bulimic Behaviors may result in electrolyte, fluid, and mineral imbalance, may be presenting cardiac risk, gastric irritation and bleeds, large bowl abnormalities, dental enamel erosion, peripheral muscle weakness, cardiomyopathy, and hypo metabolism. These consequences may be present despite normal weight.
- Bulimic patients of normal weight may also be severely malnourished and have serious nutritional deficiencies.
2. Court cases to site as precedent for medical coverage of eating disorders
- Simmons vs. Blue Cross and Blue Shield of Greater New York, 1989
- Starvation from Anorexia Nervosa is a physical state which should be covered by medical benefits
- State of Minnesota vs. Blue Cross and Blue Shield of Minnesota, 2001 (for the wrongful death of Anna Westin)
- Blue Cross/Blue Shield agreed to allow an independent panel of three experts to review denial of coverage. The majority decision is binding upon the insurance company if the policy holder is part of a state-regulated managed care system. (Unfortunately, these covered by a self-insured plan in Minnesota are not subject to state laws and therefore, for them, the panel’s decision is only advisory.)
- After receiving a claim, Blue Cross will make an immediate decision as to payment within twenty-four hours for urgent care and within two business days for non-urgent care. Blue Cross/Blue Shield agreed to increase access to psychiatrists and other therapists and significantly increase coverage for intensive treatment of eating disorders, which until them, it had rarely covered.
- Blue Cross had to reimburse families who paid for care out-of-pocket. The company also had agreed to consider claims by families who did not participate in the lawsuit, but who believed they were inappropriately denied coverage.
- Manhattan vs. Travelers Insurance Company (United States District Court): Until the patient is at least 85 percent of target weight, treatment is medical and should be covered by medical benefits, even if treatment takes place in a psychiatric hospital
3. Important Studies/Research to Date
- Individuals who were 90% of there body mass index (BMI) or less at the time of transfer from residential treatment to a day hospital program were more than ten times likely as someone who was above 90 percent of their ideal BMI to fail day hospital treatment and require either readmission to an inpatient unit or discharge against medical advice.
- For individuals less than 90 percent of their BMI, there is a strong economic advantage for continued inpatient treatment, because it avoids the immediate relapse and readmission for more than one third of those individuals.
- Over the past fifteen years the treatment of eating disorders has gone from longer hospitalizations for disease management to short hospitalizations for acute stabilization (average length of stay in 1984 was 149.5 days and in 1998 was 23.7). This shift to short hospitalizations has been accompanied by a significant rise in hospital readmissions. (O percent readmissions in 1984 and 27 percent in 1988). This can significantly increase the cost and duration of treatment.
- Patients of anorexia who are discharged and are still underweight had a 50 percent chance of readmission versus a ten percent chance for readmission for those who were discharged after full weight recovery.
Assuming treatment consisting of inpatient weight restoration with a gradual step-down to partial hospitalization program and them outpatient treatment, the treatment is cost effective when looking at cost per year of life saved, as compared to any other medical interventions.
- 10-15 percent of people with anorexia will die form their eating disorder. This is the highest mortality of any psychiatric illness.
- The risk for death for people with eating disorders is increased with the longer duration of the illness.
- 1-3 percent of people with bulimia will die.
- The longer someone has bulimia, the worse the outcome.
- If children and young adolescents with anorexia do not receive intensive intervention, severe and permanent stunting of growth will occur.
People under the age of fifteen with strong eating-disordered attitudes and a low rate of weight recovery during admission, need a longer hospitalization and a period of weight management before discharge. Upon discharge, they require a step down to intensive therapy in a day program.
- If girls with eating disorders do have stunted growth, catch-up growth is possible. However, to achieve this, they need long-standing weight gain. The sooner this is achieved the better, because the capacity for growth will eventually decline.